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Our mental health system is unable to provide care to all who need it: there are too few providers and many clients cannot afford or access it. There is a need to creatively rethink how to offer care to more in need. One way is through self-help workbooks that allow clients to work on problems at their own pace while assisted by limited paraprofessional support.
British National Health Service guidelines currently endorse practitioner-supported Cognitive Behavioral Therapy Self-Help (CBT-SH) for depression. The National Health Service currently offers CBT-SH to over 100,000 clients annually, but the intervention suffers from a high drop-out rate.
Practitioner-supported Mindfulness-Based Cognitive Therapy Self-Help (MBCT-SH) is one possible alternative to CBT-SH, but its comparative efficacy is unknown. Strauss et al. [JAMA Psychiatry] conducted a randomized controlled trial comparing CBT-SH to MBCT-SH on clinical outcomes and cost effectiveness.
The researchers randomly assigned 410 clients with mild-to-moderate depression (62% female; 86% Caucasian; median age = 32) to practitioner-supported CBT-SH or MBCT-SH. Initial diagnosis and level of depression was established by structured clinical interview and self-report.
Participants were handed CBT or MBCT self-help workbooks and provided with six structured face-to-face or telephone 30-45 minute sessions with a psychological well-being practitioner focused on workbook material. “Psychological well-being practitioner” is a paraprofessional designation created through the British National Health Service’s Improving Access to Psychological Services (IAPS) initiative.
The CBT workbook used in this study was one already in wide use in IAPS programs. The MBCT workbook was The Mindful Way Workbook: An 8-Week Program to Free Yourself from Depression and Emotional Distress written by the MBCT co-founders. Participants were given up to 16 weeks to complete the workbook curricula.
Participants were assessed on measures of depression, anxiety, quality of life and mindfulness at baseline, 16 weeks (post-intervention) and 42-week follow-up. Drop-out rates for both groups were similar (28%).
MBCT-SH participants reported greater reductions in depression at post-intervention than CBT-SH participants (d=-0.36) but the group difference was no longer significant at 42 weeks. MBCT-SH participants also reported greater improvement in anxiety than CBT-SH participants at postintervention (d=-0.23), but not at 42 weeks. The absence of significant differences at 42 weeks reflects a continued improvement in depression for both groups.
The direct costs of providing treatment were $209 for MBCT-SH and $202 for CBT-SH. Other health care and social costs were higher for the CBT-SH group ($1,684) than the MBCT-SH group ($923). The increased CBT-SH costs were due to participants receiving more individual psychotherapy outside of the program, receiving more general practitioner visits, and the higher psychotropic medication usage.
The results show MBCT-SH superior to CBT-SH as a treatment for mild-moderate depression in terms of post-intervention mental health outcome and lower health care and social costs. Findings make a case for considering MBCT-SH to be at least as effective as CBT-SH and including it within the IAPS initiative.
Strauss, C., Bibby-Jones, A.-M., Jones, F.,... Cavanagh, K. (2023). Clinical Effectiveness and Cost-Effectiveness of Supported Mindfulness-Based Cognitive Therapy Self-help Compared With Supported Cognitive Behavioral Therapy Self-help for Adults Experiencing Depression: The Low-Intensity Guided Help Through Mindfulness (LIGHTMind) Randomized Clinical Trial. JAMA Psychiatry.
Link to study
Treatments for excessive alcohol use are often only moderately successful, and clinicians are always on the lookout for more effective interventions. Mindfulness-Based Relapse Prevention (MBRP) is a promising intervention that combines standard cognitive-behavioral relapse prevention with teaching substance users to mindfully resist acting impulsively on urges.
Most existing MBRP research with persons with alcohol use disorders does not compare MBRP to other empirically validated treatments. Skrzynski et al. [Journal of Studies on Alcohol and Drugs] tested the relative efficacy of MBRP to standard relapse prevention alone in reducing alcohol use in heavy alcohol users.
The researchers randomly assigned 182 heavy alcohol users (52% male; 92% Caucasian; average age = 44 years) who volunteered because they wished to reduce their drinking to MBRP or relapse prevention alone. At baseline, participants drank an average of 5 drinks per day, and had 12 heavy drinking days per month when they consumed more than 4 drinks per day. Forty-two percent also used cannabis at least once the past month.
Both treatments were delivered in eight weekly individual therapy sessions delivered over the course of 2 months, with follow-up appointments at weeks 20 and 32. Therapy was delivered by doctoral and post-doctoral psychology students with 3 days of specialized training in motivational interviewing, MBRP, and relapse prevention.
Assessments at baseline, 4, 8, 20, and 32 weeks included an alcohol use questionnaire and timeline follow-back measures of alcohol use based on self-report.
The results showed that both groups significantly reduced their scores on an alcohol use questionnaire, and their average number of drinks per day and total number of heavy drinking days significantly declined from baseline to posttreatment.
While reduction in heavy drinking days was equal for both groups at posttreatment, MBRP participants maintained their improvement in heavy drinking days in subsequent follow-up, whereas the relapse prevention group did not. By the end of the study, the MBRP participants had significantly fewer heavy drinking days than controls.
The efficacy of the treatment was equal for males and females. High levels of cannabis use led to continued decreases in the MBRP group in drinks per day and heavy drinking days in the follow-up period, but to increases in heavy drinking days in controls.
The study showed that MBRP and relapse prevention alone were equally effective in reducing drinks per day and heavy drinking days in alcohol users who wished to reduce their drinking, but only MBRP helped participants maintain their reduction in heavy drinking days out to 32 weeks.
The study is limited by potential participants being aware that the study treatment included mindfulness, and 18% of the sample had a history of experience with mindfulness. It is unclear whether the same results would obtain in a meditation-naïve cohort or one less favorable to the idea of mindfulness.
The study is also limited by the relative inexperience of the students conducting the MBRP and relapse prevention interventions.
Skrzynski, C. J., Karoly, H., Ellingson, J., Hangerty, S., Bryan, A. D., & Hutchison, K. E. (2023). Comparing the efficacy of mindfulness-based relapse prevention versus relapse prevention for alcohol use disorder: A randomized control trial. Journal of Studies on Alcohol and Drugs.
Moral decision making sometimes involves weighing trade-offs between self-serving interests and causing harm to others. Social psychology experiments reveal a moral “slippery slope.” That is, once experimental participants begin making decisions that serve their own interests but harm others, they progressively become more self-serving and less concerned about harm to others as time goes on. Moral decision-making includes decisions about what actions to take as well as judgments about how ethical those decisions are.
Mindfulness training might affect how moral decisions are made and judged by cultivating a present-moment focus that reduces goal-oriented behavior (seeking future gain) or by increasing empathy for others. Du et al. [Scientific Reports] tested the effect of Mindfulness-Based Stress Reduction (MBSR) on moral decision-making involving tradeoffs between benefits to self and harm to self and others.
The researchers randomly assigned 68 meditation-naïve Chinese participants (75% female; Average age = 30 years) to either an 8-week MBSR course or a wait-list control. The MBSR protocol was the standard MBSR protocol delivered in a Chinese-language format. All participants engaged in moral decision making and judgment tasks and completed Chinese-language versions of mindfulness (the Five Factor Mindfulness Questionnaire), emotional regulation, and failures in executive control (problems in planning, impulsivity, and motivation) questionnaires one week prior to and after intervention.
In the moral decision-making task, participant pain thresholds were assessed to determine the level of electric shock needed to evoke a pain of “8” on a 10-point pain scale. Participants then engaged in a series of 96 decision making trials in which they chose between receiving various amounts of money while receiving painful shocks or giving them to another “person” in the next room. There was, in fact, no other person in the next room. Participants then rated the other “person’s” choices on the same task in terms of how moral their decisions were
Results from the study showed that mindfulness and executive control scores were significantly higher in the MBSR group as compared to controls after the intervention. While the control group showed an increased willingness to inflict harm on another as compared to oneself from pre- to post-testing (the “slippery slope” effect), the MBSR group did not (partial η2= 0.08).
Using Bayesian hierarchical drift diffusion modeling, the researchers established that the amount of money participants received for each decision had less of an effect on MBSR decision-makers than controls. In other words, MBSR suppressed the influence of increases in money on moral decision-making, whereas controls were more likely to morally justify causing harm to others when the amount of monetary compensation was sufficiently high.
MBSR did not make participants more moral compared to their own baseline but reduced the magnitude of the slippery slope compared to controls.
In terms of moral judgment, participants became less judgmental of other’s choices from pretesting to post-testing. Participants weighted the importance of money more and the importance of pain less during post-testing than pretesting. There was a difference between groups in this effect, however. For controls, the same amount of money justified more harm in post-testing than pretesting, whereas the amount of money had less of an effect on the mindfulness group’s judgment.
The study shows MBSR can shift the relative value of monetary gain in moral decision making and judgment involving harm compared to a wait-list control.
The study is limited by the lack of an active control and the possibility that group differences in moral performance may owe more to the demand characteristics of having been in a mindfulness condition than to cognitive changes due to mindfulness per se.
Du, W., Yu, H., Liu, X., & Zhou, X. (2023). Mindfulness training reduces slippery slope effects in moral decision-making and moral judgment. Scientific Reports, 13(1), 2967.
Ruminative thinking involves repetitively dwelling on negative experiences. A high level of ruminative thinking is a risk factor for depressive and anxiety disorders and is also a major feature of these disorders. Mindfulness offers a way to attend to negative experience and let content of thinking arise and fall without elaboration.
Reducing ruminative thinking may be a way to reduce the risk of developing future psychological disorders. Hilt et al. [Journal of Clinical Child and Adolescent Psychology] tested whether a mobile mindfulness app could reduce ruminative thinking in adolescents.
The researchers randomly assigned 152 adolescents (average age = 14; 59% female; 82% Caucasian) with high levels of rumination to a mindfulness or a mood-monitoring only group. Both groups downloaded the mobile CARE app on their smartphones. The app requested participants to rate their rumination and mood three times daily: once before and after school, and once before bedtime.
After completing ratings, mindfulness group participants engaged in mindfulness meditations of varying lengths depending on the free time they had available.
Meditations were guided by written instruction (1 minute meditations) or audio recordings (3-12 minute meditations). The meditations involved focus on the breath, body sensations, or sound. Meditation opportunities were provided 67% of the time at the end of rating sessions, and 85% of the time when participants reported sadness or anxiety. The mood-monitoring only group rated rumination and mood without the opportunities for meditation.
After three weeks, participants were no longer prompted to use the app but could continue using it if they liked. Participants were assessed at baseline, post-treatment, and 6-week, 12-week, and 6-month follow-up on self-report measures of rumination, depression, and anxiety.
The results show the mindfulness group had significantly reduced levels of rumination (d=0.43), depression (d=0.24), and anxiety (d=0.25) compared to controls at immediate post-test. The aggregate rumination scores (but not depression and anxiety scores) in the mindfulness group remained significantly lower than controls at 6-week follow-up, but not on the subsequent follow-ups.
A mediation analysis showed that post-treatment decreases in depression and anxiety were due to the decreased rumination scores predicted by the mindfulness group.
The study shows that brief app-prompted mindfulness meditations can reduce rumination, depression, and anxiety in ruminative adolescents better than mood-monitoring alone. These effects are not long-lasting and tend to fade within 6-12 weeks.
The study is important because most adolescents who ruminate do not receive any professional psychological care, and an inexpensive, easily deployable app may reduce some degree of rumination. The study is limited by the absence of a no treatment control or a meditation app without mood-monitoring.
Hilt, L. M., Swords, C. M., & Webb, C. A. (2023). Randomized Controlled Trial of a Mindfulness Mobile Application for Ruminative Adolescents. Journal of Clinical Child & Adolescent Psychology.
Mindfulness interventions often combine teaching a skill (attentional focus) with teaching an attitude (non-judgmental compassion). When mindfulness interventions successfully affect a target behavior, it can be challenging to discern which of these two training features effectively caused the change. To disambiguate these factors, O’Hare & Gemelli [PLOS One] tested the effects of focused-attention training versus self-compassion training on college students’ well-being, academic performance, and brain activity.
The researchers assigned 37 students in one undergraduate biopsychology class to focused attention training and 35 students in a separate undergraduate biopsychology class to self-compassion training. Both classes were taught by the same instructor and all non-study intervention content was standardized. Classes were similar in student age and gender distribution (average age = 23 years; 86% female).
Students received extra credit for participating in each of three baseline assessment activities: granting permission to have their class academic test grades analyzed; completing self-report measures related to health; and having their EEGs monitored while engaging in a computer-presented attentional task.
Following baseline assessment, students participated in 10 weeks of in-class focused-attention or self-compassion training. The first five minutes of one class was devoted to focusing attention on the breath without mind-wandering, and the first five minutes of the other class was devoted to focusing on self-compassion phrases (“may I be happy,” “may I be calm,” “may I be well”). The classes met twice a week for a total of 20 possible sessions. At the end of the semester, students were reassessed on self-report measures and the computer-presented attentional task.
The attentional task involved correctly identifying the direction a computer cursor faces (either < or >) when flanked by distracting cursors facing in the same or the opposite direction. Each trial was preceded by the presentation of an emotionally negative or neutral word.
EEGs were recorded, and evoked-response potentials (ERPs) to each trial analyzed for the magnitude of N2 and P3 waveform components. N2 is a negative waveform occurring about 200 milliseconds (ms) after stimulus presentation that is associated with conflict monitoring. N2 is larger when incongruent flanking stimuli are present. P3 is a positive waveform occurring about 300 ms after stimulus presentation and associated with selective attention. P3 is smaller when people are better able to ignore irrelevant emotional stimuli.
The results showed the self-compassion group showed significantly larger improvements on measures of anxiety (d =0.70), stress (d =0.80), and depression (d=0.92) than the focused-attention group. Positive affect decreased for the focused-attention group while remaining stable for the self-compassion group (d=0.63). The self-compassion group also outperformed the focused-attention group on two of four academic exams covering the course material (d=0.56 and d=0.79).
The focused-attention group showed significantly (partial η2=.13) shorter attention task reaction times (average = 80 ms) as compared to the self-compassion group when flanking cursors were incongruent with the target cursor compared to the self-compassion group (109 ms).
Only 22 students (11 in each class) had useable EEG ERP data. The self-compassion group had significant reductions in N2 from pre- to post-testing for those trials preceded by negative emotional words, while the focused-attention group did not (partial η2=0.36). The self-compassion group also had significant pre-post reductions in P3 for those trials preceded by negative emotional words, while the focused-attention students did not (partial η2=0.40). These results suggest better emotional regulation for the self-compassion group.
The study shows that short bouts of self-compassion training delivered in class over the course of one semester improves academic test performance and self-reported well-being, as well as emotional regulation as measured by ERPs. The focused-attention group had faster reaction times on an attentional task.
The study is limited by the absence of random assignment of students to class, the lack of an inactive control, the small number of students with useable ERP data, and the brevity of its intervention.
O’Hare, A. J., & Gemelli, Z. T. (2023). The effects of short interventions of focused-attention vs. self-compassion mindfulness meditation on undergraduate students: Evidence from self-report, classroom performance, and ERPs. PLOS ONE.
Some types of human behavior are habit-like. That is, an individual will respond to a stimulus with little-to-no awareness of the reward for performing the behavior. Other responses appear to be more intentional and goal directed. That is, an individual acts with conscious awareness of the relationship between the behavior and likely rewards.
Mindfulness training may make people more sensitive to and aware of reward contingencies, thereby giving them greater control over their behavior.
Chen & Reed [Journal of Behavior Therapy and Experimental Psychiatry] performed an experiment to see whether a brief mindfulness intervention could make an operantly conditioned behavior less like habitual and more like goal-directed behavior. Goal-directed behaviors are more under conscious control, more easily guided by verbal behavior, and more easily deliberately modified.
The researchers randomly assigned 52 meditation-naïve college undergraduates (average age = 20 years; 64% female) to a mindfulness, mind-wandering, or “no treatment” condition. The mindfulness condition involved 15 minutes of breath-focused meditation after one-time brief verbal instruction. Mind-wandering participants were told to “let their mind wander” for 15 minutes. “No treatment” participants were given 15 minutes to do whatever they wanted (look at their phones, read, rest, etc.).
After the 15 minutes were up, participants engaged in a conditioning “game” on a computer. The aim of the game was to earn as many points as possible by pressing a computer space bar, but participants were not informed about how many or what frequency of space bar presses would earn points and had to learn the optimal strategy by experience.
The researchers compared rates of responding to random ratio versus random interval reward schedules following a mindfulness, mind-wandering, or control intervention. Ratio schedules provide rewards after a set number of responses, while interval schedules provide rewards for responses after a set time interval has elapsed.
Behavior typically occurs in bursts of activity called “bouts.” The initial response at the onset of a bout (“bout-initiation”) is “habit-like” in that it is relatively insensitive to reinforcement schedules.
Responses after a bout has already begun (“within-bout” behavior) are more sensitive to reinforcement schedule and more goal directed. Within-bout response rates are higher during ratio than interval reward schedules, while bout-initiation rates are the same for either schedule. The researchers sought to discover whether mindfulness training could make bout-initiation responses more sensitive to the influence of reward schedule.
Participants started off with 100 points and pressed the computer space bar to earn additional points. Each space bar press cost 1 point, but if they were on a trial for which a reward was available, the space bar press earned 40 points. There were four eight-minute periods of play with each period divided into 4 minutes on a ratio schedule followed by 4 minutes on an interval schedule.
The changeover from ratio to interval was signaled by a color change in a box on the computer screen. The number of reward points available within each 4-minute interval schedule was yoked to the number of reward points received during the prior ratio schedule.
The results showed that, as expected, overall response rates were significantly higher during the ratio than during the interval schedule (η2p = .72) for all groups. Also, as expected, within-bout response rates were higher during ratio than interval without any between experimental group differences.
Most importantly, bout-initiation rates were the same for the ratio and interval schedules for the mind-wandering and control groups but not for the mindfulness group (η2p = .12). The mindfulness group alone had a significantly higher rate of bout-initiation responses to the ratio than the interval schedule (η2p = .26).
The study shows that a brief mindfulness meditation can make habit-like behavioral responses more sensitive to reward schedules. This supports the hypothesis that mindfulness increases awareness of previously unconscious reward contingencies related to performing a behavior.
The researchers did not check to see if there was a difference to the extent in which participants in different groups could verbalize their awareness of the reward contingencies in relation to their behavior.
Chen, X., & Reed, P. (2022). The effect of brief mindfulness training on the micro-structure of human free-operant responding: Mindfulness affects stimulus-driven responding. Journal of Behavior Therapy and Experimental Psychiatry.
Older adults on average exhibit signs of mild cognitive impairment compared to younger adults. It is not clear how much of this normal decline in memory and cognitive functioning is inevitably due to aging, and how much might be counteracted by healthy lifestyle changes.
Lenze et al. [JAMA] conducted a large-scale, multi-site, randomized, controlled trial to test whether mindfulness meditation and/or daily exercise could reduce cognitive impairment in older adults compared to an active control group. Prior studies had shown some support for both types of intervention, and many health experts recommend exercise to counteract cognitive impairment.
The researchers randomized 585 older adults with subjective mental decline but without dementia (average age = 71 years; 72% female; 82% Caucasian) to Mindfulness-Based Stress Reduction (MBSR), an exercise group, MBSR + exercise, or a health education control. MBSR was delivered in the standard 8-week plus half-day retreat format.
After the initial eight week course, participants received monthly booster classes for the remaining 16 months of the study. The program encouraged 60 minutes of daily home meditation practice throughout the length of the study.
The exercise program focused on aerobic exercise, resistance training, and functional exercises. The program met for two 1.5 hour classes weekly for the first six months, and then once weekly for the remaining 12 months of the study. A combined total of 300 minutes of exercise per week was recommended. Participants in the combined MBSR+exercise group participated in both full programs simultaneously.
The health education control met for the same session length and frequency as the MBSR group and offered a didactic curriculum focused on leading a healthy lifestyle.
Participants were assessed at baseline and 6- and 18-month follow-up on a neuropsychological battery assessing memory and cognitive functioning as well as measures of functioning in activities of daily life and quality of life. Participants had structural MRIs taken of hippocampal volume and dorsolateral pre-frontal cortex (dlPFC) surface area and cortical thickness.
Additionally, participants were assessed on measures of physical health and fitness including aerobic fitness, insulin sensitivity, body fat, plasma cortisol, sleep quality, and body strength. Retention in the trial was good, with 97% of participants completing the 6-month assessment and 81% completing the 18-month assessment.
The results showed no significant differences between study groups on memory and cognitive function at either 6- or 18-month follow-up. All groups showed a reduction in hippocampal volume and dlPFC surface area and cortical thickness at 18 months consistent with normal atrophy due to aging.
Contrary to expectation, the reduction in hippocampal volume was significantly greater in the MBSR group. Only the exercise groups showed significant improvement in aerobic fitness, physical strength, and sleep quality over time.
The study showed that, relative to a health education curriculum, neither mindfulness nor exercise improved memory or cognitive functioning or slowed brain tissue atrophy in this cohort of older adults with subjective cognitive complaints. The study participants were mostly college educated, Caucasian females with no evidence of dementia, and these findings may not generalize to clinical populations.
Lenze, E. J., Voegtle, M., Miller, J. P.,... Wetherell, J. L. (2022). Effects of Mindfulness Training and Exercise on Cognitive Function in Older Adults: A Randomized Clinical Trial. JAMA, 328(22), 2218–2229.
Sarcoidosis is a relatively rare multisystem immune disorder that causes inflamed lumps of tissue (called granulomas) to form and adhere to various body organs. Common symptoms include fatigue, lack of energy, shortness of breath, cough, and skin rashes/nodules. Treatment may involve the use of nonsteroidal anti-inflammatory drugs, corticosteroids, pulmonary rehabilitation, and/or physical training.
Kahlmann at al. [Lancet Respiratory Medicine] tested whether an on-line version of Mindfulness-Based Cognitive Therapy (eMBCT) reduces stress and fatigue in patients with sarcoidosis.
The study randomly assigned 99 Dutch adults with sarcoidosis (average age = 50 years; 59% female) who scored >21 points on a fatigue scale to receive standard care plus eMBCT or standard care alone. eMBCT is an 8-session online mindfulness-based cognitive therapy program initially designed to treat fatigue in cancer patients.
Participants were deemed to have completed the program if they completed 6 of the 8 sessions within a six-month window. They were also encouraged to engage in additional audio-guided home practice 30-minutes a day, 6 days a week.
Seventy-eight percent of the participants who began eMBCT completed at least 6 sessions in six months. It should be also noted, however, that a third of the potential participants assigned to eMBCT declined participation following an initial explanation of what the program entailed. Many thought it too time-consuming or had negative associations with mindfulness. This high decline rate (and the COVID pandemic) caused researchers to change their assignment protocol midway through, assigning a higher proportion of participants to the eMBCT than initially planned.
Participants were assessed at baseline, after program completion (or for controls at 3 months) and at three months after completion (or for controls at six-month follow-up). The study primary outcome was a change in fatigue ratings. Secondary outcomes were changes in sarcoidosis health status, anxiety, depression, and mindfulness (Frieburg Mindfulness Inventory).
Results showed that by post-intervention, the fatigue levels in the eMBCT group decreased significantly from baseline (-4.5 points) while controls showed no such significant decline (-0.9 points).
At six-month follow-up, eMBCT participants largely maintained their improvement (-4.0 from baseline), while controls slightly improved (-1.9 from baseline).
At post-intervention, 60% of the eMBCT group had a clinically meaningful improvement in fatigue level (defined by either a ≥ 4 point or 10% change) while only 26% of the controls had a clinically meaningful improvement.
Patients in the eMBCT group also showed significantly larger decreases in anxiety and depression and improvements in mindfulness and overall health status than controls at post-intervention and follow-up.
The study supports eMBCT as an effective treatment for reducing sarcoidosis-related fatigue. The study is limited by its reliance on a treatment-as-usual control instead of an active comparator. The fact that many mindfulness and control patients were assessed at different time intervals relative to the completion of the intervention also complicates study interpretation.
Kahlmann, V., Moor, C. C., van Helmondt, S. J., et al. (2022). Online mindfulness-based cognitive therapy for fatigue in patients with sarcoidosis (TIRED): A randomised controlled trial. The Lancet Respiratory Medicine.
Many older adults suffer from chronic arthritic knee pain. Over 700,000 Americans undergo total knee replacement surgery every year. While most patients benefit from knee replacement, up to a third of patients report persistent post-operative pain.
Pester et al. [Pain Medicine] conducted a pilot trial to test whether a brief mindfulness-based program reduces postoperative pain levels in a sample of patients undergoing total knee replacement.
The study recruited a sample of 22 Boston-area patients (age = 68 years; 55% female; 82% Caucasian) planning to undergo knee replacement and willing to participate in a mindfulness training intervention with a matched control sample of 22 Boston-area patients (age = 66 years; 55 % female; 91% Caucasian) participating in a larger knee replacement study not involving mindfulness training.
The samples were matched on age, arthritis diagnosis, stable medication dosage, and English language proficiency as well as the absence a variety of comorbid conditions (substance abuse, sleep disorder, autoimmune disease, neuropathy, dementia, and psychosis).
The mindfulness program was called Mindfulness-Based Cognitive Behavioral Therapy and was delivered in four single-hour sessions. The first and last sessions were delivered in person, and the second and third sessions were delivered via telephone. The first two sessions were delivered pre-surgically and the last two sessions post-surgically.
All sessions were taught by a clinical pain psychologist. The program included in-session practice and homework involving the body scan, sitting meditation, and lovingkindness meditation as well as cognitive-behavioral psychoeducation focusing on pacing physical activity, coping strategies, and avoiding catastrophizing about pain. The control group received knee surgery care treatment as usual.
Participants were assessed at baseline, six-weeks, and 3-and-6 months post-surgically on self-report measures of pain severity, catastrophizing, and interference with activities of daily living as well as measures of depression, and anxiety.
The results indicated that the mindfulness group showed a significantly lower pain score than controls at six weeks (partial η2=.12) with a non-significant trend towards reduced pain interference in their daily activities compared to controls (partial η2=.08).
An analysis of within-group effects at six weeks showed the mindfulness group experienced significantly reduced pain levels compared to their own baseline (partial η2=.33) but controls did not (partial η2=.00).
The groups did not differ at 3- and 6-month follow-up when both groups showed significant large reductions in pain over baseline. This was to be expected given most post-surgical pain resolves on its own over time.
The mindfulness group showed a significant reduction in pain catastrophizing scores at six weeks compared to their own baseline, but the control group did not. There were no between group or within group changes in depression and anxiety.
Reductions in pain catastrophizing scores were significantly associated with reductions in pain severity scores (r=.51).
The study shows that brief mindfulness training that includes elements of cognitive-behavioral therapy can reduce post-operative pain and speed recovery immediately after total knee replacement surgery. It appears this effect is due, at least in part, to a reduction in pain catastrophizing.
The study is limited by its lack of randomization, small sample size, and reliance on a standard care control.
Pester, B. D., Wilson, J. M., Yoon, J., Lazaridou, A., et al. (2022). Brief Mindfulness-based Cognitive Behavioral Therapy is Associated with Faster Recovery in Patients Undergoing Total Knee Arthroplasty: A Pilot Clinical Trial. Pain Medicine.
Arthroscopic surgery of the knee and shoulder involves inserting a pencil-thin lens and lighting system though a small incision in the human body to view injured connective tissue. Joint repair is then performed with specialized instruments inserted through separate small incisions.
Although orthopedic residents learn to perform this precise surgery on arthroscopy simulators, it is often hard for trainees to retain a high level of proficiency. In part, this is because surgical performance is negatively impacted by factors such as operating room distractions and the surgeon’s mental state.
Li et al. [Arthroscopy] tested whether a mindfulness meditation app could improve orthopedic residents’ performance during arthroscopic surgical simulation as well as reduce stress and distraction.
The researchers randomly assigned 43 male meditation-naïve and arthroscopically-naive orthopedic residents in Guangzhou, China (average age = 26 years) to one of three training conditions. On the first day of the study, all residents attended a didactic lecture on knee arthroscopic surgery and performed practice surgery using an arthroscopic simulator. Residents continued simulator practice until they attained two consecutive perfect scores on a set of surgical tasks.
Performance scoring was calculated by a pre-programmed simulator algorithm using a scoring system developed by the Arthoscopy Association of North America. It included measures like procedure time, camera path length, and degree of simulated cartilage injury.
After that initial arthroscopic training, two of the groups meditated 10-minutes a day for a total of 10 days using the Tide smartphone app. The app included guided audio meditations focusing on topics such as acceptance, calmness, and bodily and emotional awareness.
On day 11, residents were re-evaluated on the arthroscopic simulator performance. One-half of the meditation-trained residents meditated for 10 minutes immediately prior to the evaluation, and the other half did not. Residents reported their stress and mindfulness (Cognitive and Affective Mindfulness Scale-Revised) on day 1 and day 11 of the study.
The results showed that meditation-trained residents who meditated immediately before the simulator evaluation performed significantly better than meditation-trained residents who did not meditate immediately before the evaluation. This improvement was noted on several measures including total simulator score, surgery completion time, and injury to cartilage.
In addition, meditation-trained residents who did not meditate immediately prior to the evaluation showed significantly less skill deterioration over the course of the eleven days than residents in the non-meditation control.
Both groups of meditators showed significantly reduced stress over time compared to the non-meditators who reported increased stress levels (partial η2=0.67). Mindfulness scores improved for both mindfulness groups and declined for non-meditating controls (partial η2=0.50).
The study shows meditation app use can reduce the normal deterioration in arthroscopic surgical skills over time, and that meditating immediately before a surgical evaluation can improve surgical performance by orthopedic residents. Meditation may accomplish this by reducing stress and improving attentional skills during a surgical task.
The study’s generalizability is limited by its reliance on a male-only sample and a simulated rather than real-life surgical outcome, and by the absence of an active control group.
Li, W., Meng, X., Zhang, K.-J., Yang, Z., Feng, Z., Tong, K., & Tian, J. (2022). Meditation Using a Mobile App Improves Surgery Trainee Performance: A Simulation-Based Randomized Controlled Trial. Arthroscopy: The Journal of Arthroscopic & Related Surgery.
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